There's a hint of Missouri in the modest, plainspoken voice of James B. Peake, a 63-year-old St. Louis native who grew up the son of an Army nurse mom and an Army officer dad. It's a voice that belies the remarkable collection of military, medical and business titles he has attained. Cadet. Second lieutenant. Doctor. Lieutenant general. Surgeon general. Executive vice president. Chief operating officer. Last December, he added one more to the list, when he was confirmed to become the sixth secretary of Veterans Affairs. He replaces Jim Nicholson, a fellow West Point grad, who resigned last October. Peake will fill the cabinet slot for the remainder of the Bush presidency.

On the day Peake was sworn into office, President Bush summarized the new secretary's challenge this way: "Dr. Peake takes office at a critical moment in the history of this department. Our nation is at war, and many new veterans are leaving the battlefield and entering the VA system. This system provides our veterans with the finest care, but sometimes the bureaucracy can be difficult."

Senate Veterans Affairs Committee member Patty Murray, D-Wash., often a critical voice about VA's leadership during the Bush administration, told USA Today after Peake's confirmation that she believed the secretary's "heart is in the right place, but this job will take more than promises. He needs to work every day to overcome the bureaucratic ineptitude, backlog of claims, wait times and other challenges our veterans face every day."

The first doctor and first general to serve as VA secretary, Peake knows he is on a short clock with a change in administration looming at year's end. He told The American Legion Magazine that despite the brevity of his span at VA, he hopes to guide many long-term improvements.

Q: Why do you think the president called your time as VA secretary "a critical moment in history"?A: It's a critical era because we are a nation at war. For the first time in a long time, we have soldiers, sailors, airmen and Marines in harm's way, with multiple deployments. We've got a new generation of combat veterans coming back.

Q: VA's health-care system seems to be evolving with this new generation. The polytrauma model that seems to have been tailored specifically for them, in which veterans receive medical care, mental health, occupational therapy, job placement, spiritual and family services under one roof at VA ...A: Another way to say that is it's veteran-centric.

Q: Is that the general direction VA health care is heading?A: Where it's appropriate, I think that's exactly where all medicine is going. You read about family-centric care, patient-centric care ... for us it's veteran-centric care. Medicine is a team sport. You need all the modalities coming together to make sure the whole patient is taken care of. It's like putting mental health into our primary-care clinics. That's not just for OIF-OEF (Iraq and Afghanistan veterans). It enhances care for everybody.

Q: Today's generation of combat veterans seems to have established its own unique set of health‑care needs. A: It has. A lot of people don't recognize the huge shift in the medical paradigm for the military, in terms of rapid evacuation. A lot of people see it and get a sense of it from TV. It's a long ways from the convalescent hospitals we had when I was in Vietnam, where people sat for months in-country. Now, these young men and women find themselves back at Walter Reed within 48 or 72 hours after being injured.

Q: And soon out of DoD and into the VA system. How do you see that collaboration evolving in years to come?A: I'm for blurring the line between the two systems. I think you should be able to get your acute care at Walter Reed, get your polytrauma rehab at one of our (VA) places, and move back on active duty and return to your unit. We don't want this artificial distinction.

Q: What is happening to blur the line between DoD and VA on disability evaluations and ratings? A: We're just getting into it. The pilot program basically is that the Department of Defense will make a determination if the soldier, sailor, airman or Marine is fit or unfit for duty. VA will, in one process, do the physical examination - whatever the claim conditions are - and that information is provided back to DoD. Essentially, you have DoD making the decision. The rating is a single comprehensive rating. And then, the unfitting condition will determine whether it's a medical retirement or not a medical retirement.

Q: And that disability rating would follow the person into the VA system?A: Sure. Then you're done. You're in the system. You get your check within 60 days.

Q: The Dole-Shalala Commission recommended something of a revolution in terms of VA-DoD collaboration with federal recovery coordinators to help transitioning veterans.A: Dole-Shalala has given us a great blueprint. Details have to be worked out. We are already moving forward with the federal recovery coordinators. A lot of things have been done since Dole-Shalala started, already complementary to (VA) activities. Now, we've got to get them together. It's not VA doing it. It's not DoD doing it. It's us figuring a way to do it together, to marshal our forces so we are sharing ideas and knowledge.

Q: What kind of oversight will VA have with the federal recovery coordinator program?A: We're not developing it for VA. VA happens to be the home. We have the responsibility for housing it. But we are doing it in tandem with DoD. We also have some consultation with public-health services. The idea is that you have someone who is watching over the long-term recovery plan that is made for these kids and realizing that's going to change over time as their needs change.

Q: What do you think the 2009 VA budget recommendation will mean for the future of VA?A: Well, $93.7 billion is a lot of money. We ought to be able to do some good stuff with it. We want to continue to expand our primary-care base where we can provide greater outreach and improve our access. As I look at what this budget can do, we will essentially be able to eliminate the 30-day waiting list by the end of 2009. We brought it down substantially just this last year. That's one thing. Mental health is something else we are all concerned about. We want to make sure we've got the right infrastructure out there. We have to hire people, too. This gives us money to do that.

Q: Again this year, the administration has recommended the introduction of enrollment fees and higher co-payments for veterans, a proposal that has annually failed to get through Congress. How do you think this year's version will sell on the Hill?A: Really, it's a matter of equity. What is right? I'm a military retiree. I pay my annual enrollment fee to be a part of TRICARE. And I know a lot of retirees who feel that way, that it's right. It also encourages people to come in and not cherry-pick our services but actually get more comprehensive care because they will have invested in our system. I appreciate that some people don't like the idea of it. But I think it's a reasonable thing to ask.

Q: Does this year's proposal differ?A: Same as last year. There's a graduated scale. You don't pay anything if you are below $50,000 a year. You don't hit $750 a year until you make $100,000 a year.

Q: And that money would go back to VA care?A: It actually goes to the Treasury. It doesn't affect our budget at all. It's not something that somebody is going to have to make up in our budget if we don't get it. It's neutral.

Q: Over the past eight years, VA has not complied with the long-term care standards - in terms of bed count across the system - laid out by the Millennium Health Care Act. Can you explain?A: The whole nation is moving away from institutional care. What you really want is people functioning within a community, within their families. And so we've got about a 28-percent increase in our non-institutional care in 2009. I think that's the right way to go. We have 32,000 people with telemedicine in their homes. That's pretty powerful. I'm not sure any other system in the world has that. Where would you rather be, in a nursing home or in your own bed?

Q: Do you foresee greater use of outside-contracted services?A: The issue is, where do we have the need? And then, let's figure the best way to provide those services in an equitable, fair and efficient way. If we need to contract, then we need to do that, and we are doing it around the country. Our focus ought to be to do the right thing.

Q: What about VA's medical-school affiliations? A: I think that's one of our greatest strengths. I see those partnerships continuing.

Q: Some of these partnerships have influenced VA construction projects, which have not moved forward like veterans in many markets thought they would after the Capital Asset Realignment for Enhanced Services (CARES) plan was released in 2004.A: No one can recapitalize a system as large as ours in one fell swoop. Our job is to plan and to do the best we can. CARES was 2004. We had 156 CBOCs (community-based outpatient clinics) on the CARES list. Twenty-four of those have since been judged we don't really need, plus there are others that weren't even envisioned when we did CARES. You know, in the Army, we used to say the plan never survives first contact with the enemy.

Q: Would it be valuable to do another study like CARES?A: We have to be sure we have a model that's adjusted to the 21st century. Health care has changed. So much is done in the outpatient environment. Instead of thinking every place ought to have a monolithic hospital, maybe what we need is an ambulatory health center.

Q: How do you convince veterans of that?A: I think people are reasonable. You've just got to explain it, talk to them, and understand what their needs are. If they are perceiving something different ... sometimes perception is reality. I have breakfast meetings with veterans service organizations monthly. Ultimately, we want the same thing.

Q: Like a reduction in the VA claims backlog?A: I'm on record in hearings on this. A 1945 benefit, 1945 process around a 1945 family unit. We need to change it. You can't shift it overnight. We need to look at the 1945 system and processes and start to go paperless. We have three projects - pilots - where we are processing claims paperlessly. We have Vetsnet, which is starting to give us management data, and getting us off a "legacy" system. It allows us to know where the claim is when the vet calls. That's positive. There's a lot of movement that we need to speed up somehow. In the meantime, we are hiring more than 3,000 claims folks and making sure they are properly trained.

Another thing to know is that as the claims are going up, what's more important is the number of issues per claim is also going up. And each issue has to be separately adjudicated.

Q: Why the higher number of issues per claim?A: I don't know exactly why. The OEF/OIF veterans, I think, are getting better counseling. It makes for more complicated adjudication.

Q: You have been given a one-year window of time. How does that affect what you do?A: I won't let that dissuade me. Part of my responsibility is that we don't just bunker in for the short term but actually start looking at how we should be in the future. The priorities - VA-DoD transition, TBI, information technology, claims backlog, the issue of access that cross-cuts all of those things - are all very important. We need to keep making the bed someone else is going to sleep in.